Provider Demographics
NPI:1669895512
Name:AMBULATORY SURGICAL CENTER OF SOMERVILLE LLC
Entity type:Organization
Organization Name:AMBULATORY SURGICAL CENTER OF SOMERVILLE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED SIGNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-609-1168
Mailing Address - Street 1:1 US HIGHWAY 206
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-4101
Mailing Address - Country:US
Mailing Address - Phone:908-393-8360
Mailing Address - Fax:908-393-8375
Practice Address - Street 1:1 US HIGHWAY 206
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-4101
Practice Address - Country:US
Practice Address - Phone:908-393-8360
Practice Address - Fax:908-393-8375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-29
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ24098261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ407158Medicare PIN